Research On Anti-Fraud Strategy Of Social Medical Insurance Fixed-Point Medical Institutions

On November 14,2018,CCTV Focus Interview exposed the case of two hospitals in Shenyang City,Liaoning Province,defrauding the social medical insurance fund by employing sick-free elderly people to stay in hospital on leave.This event aroused great social concern,and caused people to think deeply about the fraud of social medical insurance.In social medical insurance,information asymmetry exists in social insurance institutions,patients and designated medical institutions,which can easily lead to social medical insurance fraud.The cases in this paper mainly involve the fraud of designated medical institutions,including the fraud of designated medical institutions alone and the fraud of conspiracy between patients and patients.Social medical insurance fraud will not only cause the loss of social medical insurance fund,but also have a serious impact on the whole medical insurance system in China,so it has important research value.This paper is based on insurance and economics as the main theoretical basis and game theory as the main analytical tool.Firstly,it gives a theoretical overview of fraud in social medical insurance and fixed-point medical institutions.Then it uses game theory to analyze Shenyang medical insurance fraud cases.The game includes the individual game between fixed-point medical institutions and social insurance institutions,as well as the patients in the conspiracy between doctors and patients.Fixed-point medical institutions play games with social security institutions to find out the influencing factors of fraud in fixed-point medical institutions through multiple games.Finally,the following countermeasures and suggestions are put forward for the identified factors: increasing the punishment of fraud in fixed-point medical institutions,controlling the agency authority of fixed-point medical institutions,improving the supervision system of social medical insurance fraud,and so on.Set up reasonable proportion of medical insurance reimbursement,reduce the conspiracy income of designated medical institutions and patients.It is hoped that this paper can provide relevant theoretical suggestions and references for the anti-fraud undertakings of designated medical institutions of social medical insurance in China.